Healthcare Provider Details

I. General information

NPI: 1003399551
Provider Name (Legal Business Name): DARREL MARTIN MIRANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 RESEDA BLVD
NORTHRIDGE CA
91324-4619
US

IV. Provider business mailing address

19609 SHERMAN WAY APT 203
RESEDA CA
91335-3430
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1051
  • Fax:
Mailing address:
  • Phone: 818-854-1263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: